Newborn Registration FormEnrolment FormMaternity Programme

SECTION A: GENERAL INFORMATION (to be completed by the expectant mother)

Details of Principal Member:

Member no nnnnnnnnn Option n Sapphire n Beryl n Ruby n Emerald n Onyx

Surname Initials Title

Tel no (H) ( ) (W) ( ) Cell phone

Email

Details of expectant mother: (if not the same as above)

Surname Title Full first name Initials

Dependant code Address

Code

Email

Tel no (H) ( ) (W) ( ) Cell phone

Preferred time of contact: Day Monday Tuesday Wednesday Thursday Friday

Time 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00

I authorise my medical practitioner to furnish and/or disclose to GEMS any fact relating to this application as well as any additional information that may be required from time to time.

Expectant mother’s signature Date nnnnnnnn

Details of general practitioner:

Surname Initials Practice no

Tel no ( )

Details of gynaecologist or midwife:

Surname Initials Practice no

Tel no ( )

Medical information:

Weight kg Height cm

Smoking n Yes n No If YES, how many per day? nIf NO n Never n Stopped less than 3 months ago n Stopped more than 3 months ago

Exercise n Never n Less than 1 hour/week n 1-3 hours/week n More than 3 hours/week

Allergies n Penicillin n Aspirin n Sulphonamides

Other

PLEASE COMPLETE THE SECTION BELOW (or refer to attending doctor or caregiver)

SECTION B: PLEASE PROVIDE INFORMATION ON YOUR CURRENT PREGNANCY(if first child, only complete this section)

Are you currently being treated for any medical conditions, eg. asthma, diabetes, hypertension, cardiac failure, HIV/AIDS,

tuberculosis or depression? n Yes n No

If YES, please list the condition/s

Do you consume alcohol? n Yes n No If YES, how much? More than two glasses per day? n Yes n No

Expected delivery date: Date nnnnnnnn First day of last menstruation period nnnnnnnn

D D M M Y Y Y Y

D D M M Y Y Y YD D M M Y Y Y Y

Tel 0860 00 4367 • Fax 0861 00 4367 • enquiries@gems.gov.za • www.gems.gov.za

SECTION C: PLEASE PROVIDE INFORMATION ON PREVIOUS PREGNANCIES

Number of previous pregnancies (including current pregnancy) nn How many children do you have? nn Do you have twins? n Yes n No Do you have triplets? n Yes n No

Have you previously experienced a miscarriage, stillbirth, death of a baby in the first 4 weeks or an ectopic pregnancy?

n Yes n No If YES, please provide us with more details:

Were any of your babies born with health problems, eg. premature, spinal cord defects, congenital defects or late still

birth? n Yes n No If YES, please provide more details, especially if surgery was necessary:

Have you had amniocentesis tests (extraction of fluid from your uterus during pregnancy) carried out for you?

n Yes n No If YES, please specify the reason for these tests:

Were any of your babies born prematurely? n Yes n No Did you carry 2 weeks over term? n Yes n No

How were your children delivered? n Normal vaginal birth n Caesarean birth

Weight of babies? Under 2500g n Yes n No Over 4300g n Yes n No

Did you experience any of the following during a vaginal birth:

n Complications n Induced labour n Vacuum extraction n Forceps-assisted birth

(delivery of baby with suction device) (delivery of baby with forceps)

What was the reason for the caesarean birth? (if applicable)

Did you experience any of the following during pregnancy?

n High blood pressure n Diabetes n Pre-eclampsia (High blood pressure with protein in the urine)

If any other problems were experienced, please provide us with more details

Indicate if any of the following complications were experienced after the birth of your child.

n Placenta retention n Postnatal depression n Severe bleeding n Breast problems n Wound infection

Condition of baby/ies after delivery:

n Breathing problems n Neonatal jaundice n Bleeding under scalp n Paralysis n Other

(Yellowing of newborn’s skin) (Unable to move one or more limbs)

Did you breastfeed your baby/ies? n Yes n No

If YES, how many weeks/months/years?

THANK YOU FOR COMPLETING THE FORM.

Please fax the completed form to 0861 00 4367.

Should you have any queries, please contact 0860 00 4367 or send an email to enquiries@gems.gov.za

IMPORTANT: You must discuss all health and treatment issues with your doctor first.